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psnet.ahrq.gov/issue/perception-usability-and-implementation-metacognitive-mnemonic-check-cognitive-errors
September 02, 2020 - Study
Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical setting.
Citation Text:
Chew KS, van Merrienboer JJG, Durning SJ. Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in…
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psnet.ahrq.gov/issue/clinical-reasoning-curriculum-medical-students-interim-analysis
March 02, 2022 - Study
A clinical reasoning curriculum for medical students: an interim analysis.
Citation Text:
Connor DM, Narayana S, Dhaliwal G. A clinical reasoning curriculum for medical students: an interim analysis. Diagnosis (Berl). 2022;9(2):265-273. doi:10.1515/dx-2021-0112.
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psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
March 12, 2025 - Review
Quality improvement and safety in pediatric emergency medicine.
Citation Text:
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
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psnet.ahrq.gov/issue/safeguarding-patients-complexity-science-high-reliability-organizations-and-implications-team
March 31, 2021 - Commentary
Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.
Citation Text:
McKeon LM, Oswaks JD, Cunningham PD. Safeguarding patients: complexity science, high reliability organizations, and implications for te…
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psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
October 05, 2022 - Study
From blaming to learning: re-framing organisational learning from adverse incidents.
Citation Text:
Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295.
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psnet.ahrq.gov/issue/translating-electronic-health-record-based-patient-safety-algorithms-research-clinical
October 27, 2021 - Study
Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites.
Citation Text:
Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites. Zimolzak AJ, Singh H,…
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety?
Rebecca N. Warburton, PhD | April 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
*
Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - EHR Copy and Paste and Patient Safety
January 1, 2018
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
Perspective
Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
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psnet.ahrq.gov/node/33747/psn-pdf
March 01, 2013 - The Literature on Health Care Simulation Education: What
Does It Show?
March 1, 2013
Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet].
2013.
https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
Perspective
The education o…
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Don’t Bite Your Tongue.
December 14, 2022
Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue
The Case
A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and
daily smoking was admitted to a hospital for ant…
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…